Nursing Elites

1. During the assessment of a client who has suffered a stroke, what finding would indicate a complication?

• A. Difficulty swallowing
• B. A slight headache
• C. High blood pressure
• D. Muscle weakness on one side

Correct answer: A

Rationale: Difficulty swallowing (dysphagia) can indicate complications such as aspiration risk, which is common after a stroke due to impaired swallowing reflexes. It poses a serious threat to the client's respiratory system. Options B, C, and D are less likely to indicate immediate complications post-stroke. A slight headache is a common complaint and may not necessarily indicate a complication. High blood pressure is a known risk factor for strokes but may not be an immediate post-stroke complication unless it is severely elevated. Muscle weakness on one side is a common sign of stroke but may not directly indicate a new complication.

2. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child?

• A. Use sunblock or protective clothing when outdoors.
• B. Include the child in regular outings with the family.
• C. Obtain any childhood vaccinations that are not up-to-date.
• D. Use diluted commercial mouthwash for mouth care.

Correct answer: A

Rationale: The correct answer is to use sunblock or protective clothing when outdoors. Methotrexate can cause photosensitivity, making the child more prone to sunburns and skin damage. Therefore, advising the parents to protect their child's skin from direct sunlight exposure is crucial. Choice B is incorrect because exposing the child to direct sunlight without protection can worsen the photosensitivity caused by methotrexate. Choice C is incorrect as obtaining vaccinations is generally avoided during chemotherapy due to the child's compromised immune system. Choice D is incorrect as commercial mouthwash may contain alcohol, which can be irritating to the child's oral mucosa, especially during chemotherapy.

3. A client with a history of chronic kidney disease (CKD) is being discharged with a prescription for epoetin alfa (Epogen). What should the nurse include in the discharge teaching?

• A. Take this medication on an empty stomach.
• B. Monitor your blood pressure regularly.
• C. Expect to feel better immediately.
• D. Avoid foods high in potassium.

Correct answer: B

Rationale: The correct answer is B: 'Monitor your blood pressure regularly.' Epoetin alfa (Epogen) can lead to hypertension as a side effect, so it is essential for clients with CKD to monitor their blood pressure regularly. Choice A is incorrect because epoetin alfa does not need to be taken on an empty stomach. Choice C is incorrect because the client should not expect immediate improvement upon starting the medication. Choice D is incorrect because while monitoring potassium intake is important in CKD, the question specifically pertains to epoetin alfa and its side effects, not potassium intake.

4. A client who is 24 weeks pregnant presents with a complaint of feeling dizzy when lying on her back. What is the best response by the nurse?

• A. Advise the client to lie on her side
• B. Encourage the client to drink more fluids
• C. Suggest the client elevate her legs when lying down
• D. Recommend the client take short walks throughout the day

Correct answer: A

Rationale: The correct answer is to advise the client to lie on her side. Lying on the side can prevent the compression of the vena cava, which can cause dizziness in pregnant women. Encouraging the client to drink more fluids (Choice B) may be beneficial for other conditions but is not the best response for dizziness when lying on her back. Suggesting the client elevate her legs when lying down (Choice C) is not directly related to the issue described by the client. Recommending the client take short walks throughout the day (Choice D) may be helpful for other pregnancy-related symptoms but is not the most appropriate action for dizziness when lying on her back.

5. The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?

• A. Restrict sodium intake
• B. Encourage high-protein meals
• C. Increase fluid intake
• D. Administer diuretics as prescribed

Correct answer: D

Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.

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